Subtle mediastinal pleural thickening on computerised tomography as a predictor of mesothelioma

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1 Subtle mediastinal pleural thickening on computerised tomography as a predictor of mesothelioma Poster No.: C-1794 Congress: ECR 2011 Type: Scientific Exhibit Authors: A. Roy, S. ellis, T. Iyngkaran ; London/UK, london/uk Keywords: Lung, Mediastinum, Respiratory system, CT, Biopsy, Diagnostic procedure, Surgery, Occupational / Environmental hazards, Neoplasia DOI: /ecr2011/C Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Purpose Malignant pleural mesothelioma (MPM) is an uncommon neoplasm with an incidence of 1 approximately 2400 new cases in the United Kingdom per year. The vast majority are attributable to prior asbestos exposure, although there is a variable but significant lag time before onset of disease. MPM has a poor prognosis and is almost invariably advanced at diagnosis. Median 2,3 survival is typically of the order of 12 months. Various modalities and regimens have been utilised in its treatment including combinations of chemo-radiotherapy and aggressive surgical resection but none have significantly altered survival. Computerised Tomography (CT) is the principal modality utilised in its evaluation. Findings suggestive of MPM include unilateral pleural effusion, irregular nodular pleural thickening and volume loss. More specific features have been shown to include circumferential pleural thickening, parietal pleural thickening >1cm and mediastinal 4 pleural thickening. However, once the above signs have developed, it is likely that the disease process is sufficiently advanced to preclude successful treatment. Diagnosis is made via biopsy, either thoracoscopically or percutaneously if the pleura is sufficiently thickened. Histologically, MPM can be subdivided into epithelioid and sarcomatoid types, the former being the more commonly encountered. We have observed that subtle mediastinal pleural thickening (# 4mm) in the presence of an ipsilateral unilateral pleural effusion may be associated with MPM and should prompt attempts to obtain definitive histology. The purpose of this study was to further explore this potential association, one which has not been previously reported in the literature. Images for this section: Page 2 of 17

3 Fig. 1: Example image of mesothelioma on chest radiography Page 3 of 17

4 Fig. 2: Example image of MPM on chest radiography with large associated unilateral pleural effusion Page 4 of 17

5 Fig. 3: Histological Patterns of epithelioid MPM. A- Tubopapillary pattern, B- Micocystic pattern, C- Papillary pattern and D- Deciduoid pattern5 Page 5 of 17

6 Methods and Materials Patient Selection: The pathology databases at our base institutions were comprehensively searched for all pleural biopsies performed between January 2005 and October Biopsies undertaken via image guided (computerised tomography or ultrasound) and thoracoscopic means were included in the analysis. This initial search revealed 1041 patients who fulfilled the above criteria. Pathology: All pathology samples were transported in formalin and analysed by consultant pathologists at our base institutions. The biopsy results included benign and malignant aetiologies. For the malignant causes, histological subtypes were recorded. Radiology: The radiology databases were then scrutinised to determine which of the initial cohort had undergone contemporaneous CT imaging (within 3 months of the biopsy) which was accessible for examination (either on PACS or physical copy film). This was performed via the demographic data (patient date of birth/unit number). As this was a retrospective analysis involving more than one institution, not all imaging was identical in terms of study protocol. However, the vast majority of CT examinations included in the study involved 5mm thick slices through the chest on a standard soft-tissue window level following intravenous contrast in the arterial phase. 126 patients were included in the retrospective analysis. 2 consultant radiologists examined the relevant CT imaging within this cohort and independently recorded the presence or absence of "subtle mediastinal pleural thickening" as defined by pleural thickening # 4mm. The observers were blinded as to the result of the biopsy at the time of recording this observation. Concordance between the two observers was required before the presence or absence of this sign was finally recorded. In cases where there was a discrepancy in opinion, the cases concerned were re-examined by both parties until a consensus was reached. Other imaging features recorded at this time included the presence of volume loss, the presence of a pleural effusion, a diagnosis of concurrent lung parenchymal malignancy and nodal disease. Basic demographic data was recorded for each patient included in the Page 6 of 17

7 analysis and other relevant information such as referral source and indication for biopsy was also recorded. Statistical analyses: The chi-squared test was used to compare counts with the null hypothesis that there is no statistically significant difference in the rates of malignancy (specifically, mesothelioma) between the test positive and test negative patients. Images for this section: Fig. 1: Example image from a CT-guided core biopsy of the pleura Page 7 of 17

8 Fig. 2: Example image demonstrating nodular, irregular pleural thickening known to be highly suggestive of MPM. Note the extensive surgical emphysema associated with a preceding pleural biopsy. Page 8 of 17

9 Fig. 3: Example image demonstrating nodular, irregular pleural thickening known to be highly suggestive of MPM Page 9 of 17

10 Fig. 4: Example image demonstrating "subtle mediastinal pleural thickening". The area of note is labelled with a white arrow. Note the contrast with the images above which show greatly more florid changes. Fig. 5: Example image of a case where although there is a large unilateral pleural effusion no subtle mediastinal pleural thickening is seen. However, the final histology demonstrated unequivocal evidence of MPM. Page 10 of 17

11 Results Figure 1 demonstrates the data in tabulated form. Figure 2 is a breakdown of the age demographics of all patients included in the analysis. Figure 3 shows a breakdown of all diagnoses. Of 126 patients included in the retrospective analysis, malignant disease was found in 53 (42%) of which 35 were MPM (27%). When distinguishing between malignant and benign causes, subtle mediastinal pleural thickening was seen in 41/53 malignant cases (sensitivity= 77%) but also in 36/71 benign cases (specificity= 49%, PPV= 53%, NPV= 74%). The incidence of malignancy was significantly higher in subtle mediastinal pleural thickening (SMPT) patients than in sign negative patients (p= ). See figure 6. Comparing MPM with other malignant causes, subtle mediastinal pleural thickening was observed in 27/35 MPM cases (sensitivity= 77%) but also 14 malignant nonmesothelioma cases (specificity= 22%, PPV= 66%, NPV= 33%). This was not statistically significant (p=0.96). See figure 7. When assessing patients with concurrent evidence of volume loss on CT, subtle mediastinal pleural thickening was observed in 21/23 malignant cases (sensitivity= 91%), but also 27/38 benign causes (specificity= 28%, PPV= 43%, NPV= 84%). This was not statistically significant (p=0.061). See figure 8. Comparing MPM with other malignant causes in only patients with volume loss, subtle mediastinal pleural thickening was observed in 14/16 MPM cases (sensitivity= 88%) but also 7 malignant non-mesothelioma cases (specificity= 0%, PPV= 67%, NPV= 0%). This was not statistically significant (p=0.32). See figure 9. Images for this section: Page 11 of 17

12 Fig. 1: Patient characteristics Page 12 of 17

13 Fig. 2: Demographic data of those included in the analysis - patient age in years Fig. 3: Diagnosis (by pleural biopsy) of all patients Fig. 4: Diagnoses in sign positive and sign negative patients - Subtle mediastinal pleural thickening (SMPT) sign presence and pathology Page 13 of 17

14 Fig. 5: Breakdown of malignant causes and sign positivity - SMPT sign presence and breakdown of malignant pathologies Fig. 6: Numbers of patients with malignant and benign diagnoses and the proportions with subtle mediastinal pleural thickening (SMPT) Sensitivity= 77% Specificity= 49% PPV= 53% NPV= 74% Page 14 of 17

15 Fig. 7: Proportions of patients with SMPT seen in malignant causes of pleural disease (MPM vs other malignant aetiologies) Sensitivity= 77% Specificity= 22% PPV= 65% NPV= 33% Fig. 8: As fig 6 but only considering those with concurrent volume loss as seen on CT Sensitivity= 91% Specificity= 28% PPV= 43% NPV= 84% Page 15 of 17

16 Fig. 9: As fig 7 but only considering those with concurrent volume loss as seen on CT Sensitivity= 88% Specificity= 0% PPV= 67% NPV= 0% Page 16 of 17

17 Conclusion In patients with unilateral pleural effusion who have undergone pleural biopsy, the presence of subtle mediastinal pleural thickening is a useful adjunctive indicator of underlying pleural malignancy. The incidence of malignancy was significantly higher in subtle mediastinal pleural thickening (SMPT) patients than in sign negative patients (p= ), although no statistically significant difference was observed between MPM and other malignant causes. In patients without a confirmed diagnosis, the presence of this feature should encourage more invasive investigative methods including pleural biopsy. References 1. Cancer Research UK. 2. Wang ZJ, Reddy GP, Gotway MB, Higgins CB, et a. Malignant Pleural Mesothelioma: Evaluation with CT, MR Imaging and PET. Radiographics 2004; 24: Aisner J. Current approach to malignant mesothelioma of the pleura. Chest 1995; 107: 332S-334S. 4. Leung AN, Muller NL, Miller RR. CT in differential diagnosis of diffuse pleural disease. AJR March 1990(154); Butnor KJ. My approach to the diagnosis of mesothelial lesions. J Clin Pathol Jun;59(6): Personal Information Page 17 of 17

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